Dupuytren’s Contracture

Overview

• Benign fibroproliferative disease affecting the palmar fascia

Risk Factors

1. Male (up to 10:1)
2. Northern European (Viking) origin
3. Alcohol
4. Smoking
5. Family history
6. Manual work
7. Diabetes
8. Anti-Epileptic drugs

Aetiology

• Overriding genetic predisposition
• Autosomal dominant with variable penetrance

Contributory Theories

1. Intrinsic
   • Metaplasia of native fascia
2. Extrinsic
   • Subdermal origin which attaches to and involves fascia
3. Free Radical Theory (more in vogue)
   • Free radicals present in hypoxic tissues (diabetics, smokers, alcoholics, manual laborers)
   • Cause cytokine release (PDGF, TNF-b, etc.)
   • Cytokines induce transformation of fibroblasts to myofibroblasts

Histopathology

• Type 3 collagen
• Myofibroblasts
• Cytokine mediated (TNF; Fibroblast growth factor)

Pathologic Stages

1. Proliferative Stage
   • Nodule & pit formation
   • Large myofibroblasts dominate
2. Involutional Stage
   • Cells align in the line of digits
   • Ratio of type 3 to type 1 collagen increases
3. Residual Stage
   • Resultant scar-like cords
   • Myofibroblast numbers decrease, leaving fibrocytes

Dupuytren’s Diathesis

• Severe Dupuytren’s characterized by:
  1. Strong family history
  2. Affliction of radial digits (thumb and index)
  3. Ectopic disease (penis - Peyronie’s, feet - Ledderhose)
  4. Garrod’s pads
  5. Bilateral disease
  6. Young presentation

Order of Digits Affected

• Ring > Little > Middle > Thumb > Index

Normal Anatomical Structures

• Bands are normal, cords are abnormal

Palmar Fascia

• Continuation of forearm fascia and Palmaris longus
• Function: Anchor skin and improve grip

Key Ligaments & Bands

• Pre-tendinous Band: Ends at distal palmar crease, in line with digits
• Spiral Bands: Bifurcation of pre-tendinous bands, lateral to digits
• Lateral Digital Sheet: Lies lateral to NV bundles in digits
• Grayson’s Ligament (Ground): Lies volar (towards ground) to NV bundle
• Cleland’s Ligament: Lies dorsal to NV bundle
• Vertical Fibres: Between palmar fascia and skin
• Natatory Ligament: Located in web spaces
• Scoog’s Fibres: Transverse fibres between NV bundles and palmar fascia
  • Up to distal crease level
  • Important in revision surgery (superficial dissection is always safe)

Pathologic Anatomy

Pits/Nodules

• Precursors of cord formation
• Lie over pre-tendinous bands
• Related to vertical fibres that anchor the skin

Cords & Contractures

1. Pre-tendinous Cord
   • Most commonly involved band causing MCPJ contracture
   • Responsible for MCPJ contracture along with natatory cord
2. Central Cord
   • Extension of the pre-tendinous cord into the digit
   • No NV displacement
3. Spiral Cord
   • NV bundle spirals around it and is displaced
4. Lateral Cord
   • From lateral digital sheet
   • Displaces NV bundle medially (uncommon)
5. Natatory Cord
   • From natatory ligament
   • Must be excised to complete correction at MCPJ level
6. Retrovascular Cord
   • Rare dorsal cord extending to DIPJ causing hyperextension
7. Abductor Digiti Minimi Cord
   • Only in little finger, displaces NV bundle medially
8. Commissural Cord
   • 1st web space cord

Diagnosis

History

• Risk factors
• Degree of disability
• Previous surgery
• Features of Dupuytren’s diathesis
• Presence of pain (pain is unusual, beware if present)

Examination

• Quantify deformity
  • Measure PIPJ with MCPJ flexed (cord crosses both joints)
  • Measure MCPJ with PIPJ flexed
• Define cords
• Skin quality
• Previous scars
• Must do Digital Allen’s test in severe deformities pre-operatively

Differential Diagnosis

• Epithelioid Sarcoma: Rare, aggressive, not confined to fascia
• Subcutaneous Lesions: GCT, dermoid cysts, trigger finger, etc.
• Primary Joint Contracture

Surgical Planning

• Considerations
  • Deformity correction feasibility
  • Skin problems
  • NV structure displacement
  • Functional aims of the patient

Management

Non-Operative

• Splinting & Steroid injections not effective
• Mild disease should be managed non-operatively as recurrence is inevitable

Collagenase Injection (Xiaflex)

• Injection into the cord
• MUA the following day if no spontaneous rupture occurs
• Selectively attacks type 3 collagen
• Approved by NICE
• CORD 1 Trial (NEJM RCT): Beneficial for MCPJ
• CORD 2 Trial: Examined PIPJ (data pending)
• Limitations: Expensive, long-term results unknown (>3 years)

Operative Indications

• MCPJ deformity >30°
• PIPJ deformity >15°
• Symptomatic patient

Markers of Poor Outcome/Recurrence

• Significant PIPJ deformity (collateral ligament & volar plate contracture)
• Young patient (more aggressive disease, longer recurrence window)
• Dupuytren’s diathesis
• Revision surgery

Operative Options

Percutaneous Needle Fasciotomy

• Good for pre-tendinous cords
• Risk of NV bundle displacement in spiral/lateral cords
• Higher recurrence, but minimal invasiveness

Skin Incisions

• Brunner’s Incision (>60° angles)
• Straight with Z-plasties (60° angle = 75% more length)
• Open Palm (McCash): Leaves large skin defects open

Fasciectomy

1. Partial/Regional Fasciectomy
   • Workhorse procedure, good correction but eventual recurrence
   • May require open wound management or grafting
2. Segmental Fasciectomy
   • Cords divided at multiple levels
   • Lower morbidity, higher recurrence
   • Reserved for elderly with low correction aims
3. Radical Fasciectomy
   • Rarely used, aims for total fascia excision
   • Recurrence still occurs

Dermofasciectomy

• For revision cases or severe primary disease
• Excision of diseased tissue with midlateral incisions
• Full-thickness skin graft from cubital fossa
• Recurrence rate 10% (low)

Post-Op Protocol

• Plaster splinting with fingers straight
• Follow-up in 1 week: Wound check & splinting
• Splinting for 6 weeks
  • Flexion exercises to prevent stiffness
  • Night splinting up to 6 months

Salvage Surgery

• Amputation: Severe recurrent disease, low-demand patient
• Corrective Arthrodesis: Recurrent disease, poor soft tissues

Complications

• Intraoperative: NV damage, vascular spasm
• Postoperative: CRPS, haematoma, wound breakdown, infection, recurrence, loss of flexion